Utilization Review Checklist
Meniscal Tear
Derived from the ACOEM Knee Disorders Guideline, edition 3 December 2019, as adopted into the California MTUS 21 September 2020. CPT 29881, 29880, 29882. ICD-10 S83.2, M23.2.
Draft — not reviewed or approved by COA. Prepared by Rette from the ACOEM guideline named above. This is not a COA document and does not reproduce COA’s own checklists.
CriteriaCheck if documented
Confirmatory Diagnosis
Any one of the following
Locking symptoms
“Possible expectations include those with locking symptoms,” — p. 150
OR
Severe tear on imaging
“severe tears,” — p. 150
OR
Frank traumatic onset
“and/or frank traumatic onset that does not generally include onset after “exercise,” “hard work,” or “twisting” events.” — p. 150
Conservative Care
Required
Attempted non-operative treatment generally including passage of at least a few weeks, NSAIDs, and activity modulation
“Thus, patients should be highly selected and have attempted non-operative treatment that generally included passage of at least a few weeks, NSAIDs, and activity modulation, and also may have included formal therapy.” — p. 150
Surgical Considerations (arthroscopic partial meniscectomy and/or repair)
Required
Arthroscopic partial meniscectomy and/or meniscal repair requested for a highly selected patient
“Arthroscopic partial menisectomy and/or meniscal repairs for symptomatic, torn menisci is recommended for highly select patients.” — p. 150
Procedures — the guideline treats each separately
Arthroscopic partial meniscectomy and/or meniscal repair
Recommended.
Strength of Evidence — Recommended, Insufficient Evidence (I) · confidence low
Read the guideline's own framing before filing: 'Relatively few patients with meniscal tears appear to be candidates for this surgery.' It names locking symptoms, severe tears and frank traumatic onset as the expectations — and expressly says onset after 'exercise', 'hard work' or 'twisting' events does NOT generally count as frank traumatic onset. In a workers' compensation setting that exclusion is likely to be quoted back at you, so describe the mechanism precisely.